How To Use CPT Code 36471

CPT 36471 refers to the injection of sclerosant into multiple incompetent veins in the same leg, excluding telangiectasia. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 36471 procedures.

1. What is CPT 36471?

CPT 36471 is a medical procedure code used to describe the injection of a sclerosing solution into multiple incompetent veins in the same leg, primarily for the treatment of varicose veins and other vascular malformations, excluding telangiectasia (spider veins).

2. 36471 CPT code description

The official description of CPT code 36471 is: “Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg.”

3. Procedure

1. The patient is appropriately prepped for the procedure.
2. The provider identifies the affected veins in the leg using ultrasound or other imaging techniques.
3. A syringe filled with a sclerosing solution is prepared.
4. The provider inserts the syringe directly into the affected veins of the leg.
5. The sclerosing solution is injected, causing the vein walls to collapse.
6. The needle is removed, and pressure is applied to stop bleeding.
7. Compression stockings or bandages may be applied to the treated area.

4. Qualifying circumstances

Patients eligible to receive CPT code 36471 services are those with multiple incompetent veins in the same leg, primarily for the treatment of varicose veins and other vascular malformations, excluding telangiectasia. It is essential to check with local payer’s local coverage determinations to decide whether it covers 36471. Some payers may cover sclerotherapy for patients with ulcers, inflammation, or other complications of the lower extremities but not for varicose vein treatment.

5. When to use CPT code 36471

It is appropriate to bill the 36471 CPT code when a provider performs the injection of sclerosant into multiple incompetent veins in the same leg, excluding telangiectasia. This procedure is typically used to treat varicose veins and other vascular malformations. It is crucial to ensure that the patient meets the qualifying circumstances and that the procedure is covered by the payer before billing CPT code 36471.

6. Documentation requirements

To support a claim for CPT 36471, the following information should be documented:

• Patient’s medical history and physical examination findings
• Diagnosis and indication for the procedure
• Details of the procedure, including the number of veins treated and the amount of sclerosing solution used
• Post-procedure care instructions and follow-up plan
• Any complications or adverse reactions encountered during the procedure

7. Billing guidelines

When billing for CPT code 36471, it is essential to follow the appropriate guidelines and rules. Some tips and codes that apply to CPT code 36471 include:

• Use 76942 for ultrasound imaging guidance performed in conjunction with 36470 and 36471.
• Do not report 36470 and 36471 in conjunction with 29520, 29530, 29540, 29550, 29580, 29581, or 29584 for the same extremity.
• Do not report 36471 more than once per extremity.
• If the targeted vein is an extremity truncal vein and injection of non-compounded foam sclerosant with ultrasound-guided compression maneuvers to guide dispersion of the injectate is performed, see 36465 and 36466.
• Do not report 36470 and 36471 in conjunction with 37241 in the same surgical field.

8. Historical information

CPT 36471 was added to the Current Procedural Terminology system on January 1, 1990. The code was changed on January 1, 2018, with the previous descriptor being “Injection of sclerosing solution; multiple veins, same leg.”

9. Similar codes to CPT 36471

Five similar codes to CPT 36471 and how they differentiate from CPT 36471 are:

1. CPT 36470: Injection of sclerosant into a single vein (other than telangiectasia) in the same leg.
2. CPT 36465: Injection of non-compounded foam sclerosant with ultrasound-guided compression maneuvers to guide dispersion of the injectate into an extremity truncal vein.
3. CPT 36466: Same as CPT 36465, but for multiple veins in the same leg.
4. CPT 37241: Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention.
5. CPT 76942: Ultrasound guidance for needle placement, including imaging supervision and interpretation.

10. Examples

Here are 10 detailed examples of CPT code 36471 procedures:

1. A 45-year-old patient with multiple varicose veins in the left leg undergoes sclerotherapy with the injection of sclerosant into three incompetent veins.
2. A 55-year-old patient with a history of venous insufficiency and multiple incompetent veins in the right leg receives sclerotherapy treatment for four affected veins.
3. A 38-year-old patient with recurrent varicose veins in the left leg after previous treatment undergoes sclerotherapy with the injection of sclerosant into two incompetent veins.
4. A 50-year-old patient with multiple varicose veins in the right leg and associated pain undergoes sclerotherapy with the injection of sclerosant into five incompetent veins.
5. A 60-year-old patient with a history of venous ulcers and multiple incompetent veins in the left leg receives sclerotherapy treatment for three affected veins.
6. A 48-year-old patient with multiple varicose veins in the right leg and associated leg swelling undergoes sclerotherapy with the injection of sclerosant into four incompetent veins.
7. A 52-year-old patient with a history of deep vein thrombosis and multiple incompetent veins in the left leg receives sclerotherapy treatment for two affected veins.
8. A 57-year-old patient with multiple varicose veins in the right leg and associated leg heaviness undergoes sclerotherapy with the injection of sclerosant into three incompetent veins.
9. A 40-year-old patient with multiple varicose veins in the left leg and associated skin changes undergoes sclerotherapy with the injection of sclerosant into four incompetent veins.
10. A 65-year-old patient with a history of venous insufficiency and multiple incompetent veins in the right leg receives sclerotherapy treatment for five affected veins.